The recommended first-line agent is phenylephrine, [4] with the notable exceptions being the patient who responds to spinal anaesthesia with bradycardia and hypotension, or has undiagnosed cardiac disease and unexpectedly requires positive inotropy.

When the concentration of cGMP-inhibited phosphodiesterase is low, it increases the intracellular level of cyclic adenosine monophosphate (cAMp), which can be considered a positive inotropy (Figure 2).

Management of postoperative PAH depends on its severity and the results of a careful evaluation; the acute right heart failure constitutes an emergency that demands aggressive treatment include maintenance of systemic perfusion pressure and avoidance of systemic vasodilators, optimization of cardiac inotropy, a lung- protective ventilation strategy, and attempting to reduce right ventricular afterload with pulmonary vasodilators.

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